Pediatric society opposes independent practice of NPs

Nurse practitioners cry foul, but the American Academy of Pediatrics says patient safety is at the core of its revamped policy on scope of practice.

By Myrle Croasdale, amednews staff. March 10, 2003.

It was a routine procedure resulting in an unexpected outcome.

The American Academy of Pediatrics dusted off its scope-of-practice policy for an update. Many meetings later, including some with nonphysician health care practitioners, the revamped policy was published in the February Pediatrics.

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Then the phones lit up, the e-mails began circulating and the National Assn. of Pediatric Nurse Practitioners publicly criticized the AAP's policy and accused the group of unprofessional and deceptive behavior.

At the center of the brouhaha is a statement from the AAP scope-of-practice policy: "The AAP ... opposes the independent practice of nurse practitioners."

20% of American children had alternative medicine treatments in 1999, up from 11% in 1994.

Carol Berkowitz, MD, lead author of the policy statement, explained, "For a nurse practitioner to open her own office and claim she can care for all types of pediatric problems, that's inappropriate."

The AAP said this is not a matter of wrangling over competition but one of maintaining quality of care. More nurse practitioners, physician assistants, psychologists, pharmacists, acupuncturists, naturopaths, chiropractors and other nonphysicians are delivering health care to children without the oversight of a pediatrician, putting the safety of children at risk, according to the AAP policy statement.

"We're advocating for children and quality of health care," Dr. Berkowitz said. "We'd be remiss to think that all self-proclaimed pediatric care providers can render the same care."

Alternative therapies bear watching

Carmelita Britton, MD, chair of the AAP's committee on pediatric work force, said, "For many, pediatrics is seen as a new frontier of opportunity, and we're seeing complementary medicine increasingly targeting pediatric populations."

Chronically ill children are most often the ones using alternative therapies, said the AAP, citing a 2000 study that reported the percentage of American children using alternative medicine rose to 20% in 1999 from 11% in 1994. There is little scientific evidence that alternative treatments are safe and effective for children, Dr. Britton said, and parents often don't inform their pediatrician of this care.

"We need to make sure the door is open," she said, so that parents will be more forthcoming.

Nurse practitioners can work without physician supervision in all but 13 states.

The AAP stressed that a team approach to children's health care is best -- a team under a physician leader, preferably a pediatrician.

This is not how NAPNP sees it. They agree on the effectiveness of working as a team, but not on the need to be supervised by a physician.

Mary Margaret Gottesman, PhD, RN, CPNP, president of the organization, said, "We don't agree on their position on pediatric nurse practitioners. We each have strengths we bring to the care of children, and we would like to be treated with the respect of a colleague, not as lower or less than, which is what their language implies."

Nurse practitioners are legally permitted to work without the supervision of a physician in all but 13 states and have prescribing privileges of various degrees in all states except Georgia, according to the American College of Nurse Practitioners.

Dr. Gottesman said she thinks that pediatricians have all along believed nurse practitioners should be supervised by physicians, but the policy statement is the first time the belief had been articulated so clearly.

Despite the hard line taken in the AAP policy statement, Dr. Gottesman said most nurse practitioners experience good working relationships with pediatricians.

"Many pediatricians honestly do have respect for us and don't see us as less than them, but that doesn't come out in their policy statement," she said.